Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, November 17, 2006

Rectifying, Redux

I remember reading in a surgical journal some years ago about the extraction of a jar of maraschino cherries from a man's rectum. Being a glass jar, and large, there were problems getting purchase (in the grasping, not the monetary sense: presumably it had already been paid for), and there was concern about breaking it. Performing some sort of version maneuver, they unscrewed the cap, emptied out the cherries, and grabbed the lip of the jar for a successful end of the case. The icing on the cake, the cherry on top. But it wasn't the process that impressed me; it was the apparent credulity with which the authors reported the mechanism of entry in the first place. The man, so they explained, had been camping and had, in answering the call of his lower intestine, sat on a branch to perform the evacuation. The branch broke, and, as luck would have it, he'd been unknowingly positioned exactly above an upright jar of cherries, and landed orificially straight upon it.

Yeah, right.

I suppose were I to sit upon a branch to perform the needed function I'd never think of looking at what was below, and I'm quite certain I'd completely overlook a jar of cherries. Nor would I wonder what the hell it was doing there, perfectly upright under a branch in the middle of the wild, nor move it. Does a bear shit in the woods? Of course he does. And he marks the territory with the fixings for a sundae.

People who people their recti with foreign objects tend to obfuscate. "No idea. Passed out at a party, woke up with the (insert insertion here) up my ass." That's what the man told me when he showed up with a candle in place. No ordinary candle this: probably three inches in diameter, it was over a foot long. How his colon accepted it without tearing, I can't say; I'd guess it had had practice. The upper end of the candle disappeared behind the lower edge of his ribs. Prodigious. A quick rectal exam in the ER clarified that there'd be no way to remove it without anesthesia. More often than not, we do such a thing under spinal anesthesia, both to avoid regurgitation if there's a full stomach, and because it very nicely relaxes the sphincter muscles. In this case, perhaps presciently, the man requested going to sleep. Good choice. It turned into a sort of monumental episode. Wick-ed tough.

Imagine a broad piece of brittle wax, lubricated, obscured at its bottom (as it were) end by tender tissues; slippery by its nature, ungraspable by its geometry. I sat between the man's legs for a goodly amount of time, trying everything of which I could think: big tongs chipped off pieces of wax and the candle squirted headward. I slid a balloon-tipped catheter along side and as high as I could wriggle it, inflated the balloon and withdrew without success. I heated a round-tipped probe thinking I could melt it in, let things cool, and pull it out. Because the north end of the candle was well above the man's ribs, I couldn't apply counter pressure to squeeze it downward. I could stretch his sphincter enough to insert most of my fingers, but the sheer size of a hand grasping a three-inch wide waxy thing and sliding back out was impossible. Even given a certain pre-existing laxity.

There were a couple of other operations going on at that late hour, and as the other surgeons finished up they drifted into my room, suggesting various orthopedic instruments unknown to me, making many and varied and uniformly unsatisfactory recommendations. After a while, it was as if I were in a Greek tragedy, with a murmuring Chorus behind me. I knew I had the ultimate option, but deferred as long as I could, trying everything up with which anyone could come. Finally, I did what I had to do: made an incision in the man's lower belly, grabbed his colon and its content with my left hand, and pushed it downward while guiding anally with my right. Took a minute, slipped it out. I'd not wanted to give the man an incision, admit him to the hospital, subject him to the embarrassment of having to explain himself to a few shifts of nurses. But I'd run out the string. I'd never claim to be great, but that night no other surgeon held a candle to me.

Not every person who packed objects was as demure. As I described in my book, one brave fellow with a vibrator lodged in the sun-free zone had great grace. Awake under a spinal anesthetic, when presented by me with the retrieved vibrator and asked "Here it is Mr Jones. What would you like us to do with it?" Calmly, he said, "Oh, how about you replace the batteries and put it back in?"

It was a rare occasion when we were able to unburden a person in the ER; it almost always required an anesthetic, since those that didn't usually would have been handled by the owner. On the one occasion we were successful, we decided to send the item to the pathology lab. The report remained posted in the ER for some time: "Normal cucumber, with feces."

FFA, before my residency, stood in my mind for "Future Farmers of America." I learned another meaning in San Francisco, after meeting a couple of members and reading their impressively well-produced monthly magazine. The first F stood for "fist." The glossy and professional pictures had at least two people in them, and generally a can of Crisco. One upper extremity was quite hidden, pretty much completely below the elbow. I don't know if their organization required dues, or if they had a secret handshake. If so, it would have been done carefully, I'd think. The one member with whom I became involved professionally required a colostomy. Let's leave it at that.

young lady with FB in rectum-story was "getting ready to take a shower, the power went off, so I lit a candle, put it on the toilet seat. While I was taking my shower the power came back on, I finished my shower, got out and sat down on the toilet seat to dry off"

Not too surprising that most of these people who end up in the emergency room tell unlikely stories -- anyone sophisticated enough to actually admit they enjoy putting things in their rectum will probably also be informed enough to use a proper butt plug, which widens out so that it can't go all the way in.

Have been out of circulation for a while, but hope to get caught back up and begin reading (and posting) in earnest again very soon. I can see that I have a lot of catching up to do here. You know, I wouldn't miss a word of it for anything!

did you read about the guy in england who, during the 'guy fawks' celebration, lit a firecracker that he placed "between his buttocks"? went to the er with burns and unspecified internal injuries. had his friends record it on their cell phone cameras.

I have found that upon entering the room the best thing to say is... "hello I'm Dr. Trench, I hate to hear about the problem you are having, so first let me say that we see this about once a week, so there is no need to feel embarassed... trust me (smile) I've probably taken the same thing out of your minister"

This invariably avoids both of us sitting uncomfortably through some bullshit "fell on it "story.

God, I love these kind of stories. When I first got out of nursing school, I worked as a Colon-Rectal surgical nurse. At first, I didn't believe all the stories our docs told the nursing staff, but it didn't take long before I had stories of my own.

Hilarious. I remember once when I worked at a psych hospital we had a patient who successfully swallowed a complete playing card--and was physically prevented from almost swallowing another . A day or so later, when she passed the card out of her system while having a bowel movement, we heard the tech who found it yell "Blackjack"....

This happened to me so many times when I was a resident. Since it was a decade ago in a different city I will share the stories.

I remember the guy who came in on the gen surg service to the ER ( I am gyn). He had an acute abdomen no idea no history why. they do an xray and see a metal object and a metal screw much further up the colon. Turns out to be a TABLE LEG -- little metal thing was the tap at the floor end and the screw is where it screws into the table. Surgeons ask him "didn't you think this wold be relevant to your ABDOMINAL PAIN?". He then tells the story of the house break in and assault where the leg was inserted (lubricated well they find out in the OR).

On the gyn service I was called to see an RN with acute pain. In the exam room she has a tennis ball stuck in her vagina. She was brought in by her tennage son and makes me promise not to tell him the real cause. She tells me "well doc you know how it is, you're married and trying to get a little spice folling around inthe closet with your husband and it slips too far inside". I really could not fully relate to that scenario.

I also remember the whole series of vacuum cleaner penis injuries my urologist friend was called to see. There were all accidental while calmly cleaning up in one's bathrobe.

But the # story was while a medical student at Boston City hospital. There was a photo inthe call room on the surgery service "wanted for all crimes - the dude brothers". Everyone who came in shot inthe butt whould say I was minding my own business when these two dudes came up and shot me! Then the police would show up and tell us of the gang fight or attempted liquor stor hold up. We wanted to know which hospital all the croiminals went to when shot since our patients were all politely minding their own buisness when stabbed or shot. Got to the point where we would say" let me guess - you were probably just minding your own business when these two dudes shot you!" and they waould say "yeah yeah you are the best how did you know!"

In residency there was a book of X-rays in the call room. By far the most memorable was an abdominal film demonstrating an enormous (Black and Decker 'mag lite' variety) flashlight lodged in the ironically named descending colon.

The caption read "Rectal foreign body. The patient was de-lighted upon it's removal"

SzD: the problem was the large diameter, and the slipperiness. Any of those methods (other than melting, which would have required a flame of some sort in an environment of noxious gasses (since other cautery devices require grounding via tissues, which wouldn't happen in wax), require the ability to grab and stabilize the candle. But the inability to do so was the problem. Had I been able to grab in such a way, I'd have been able simply to pull it out. I've been thinking about the previous corkscrew idea; I think it'd have failed for the same reason, but I wish I'd have thought of it. I have a corkscrew on my Swiss Army knife and would have been happy to have given it a shot, assuming corkscrews weren't otherwise available...

Worth a try. In this case, though, the problem was holding it in one place to allow such a maneuver. I couldn't get purchase from below with any sort of clamp, and I couldn't stabilize it by pushing on the belly, from above.

As an OR Nurse, I have come across similar situations, thankfully infrequently, but more than enough in my career of 31 years.The latest was a lime. It was to be the second case of the day and on the schedule board, it simply read, "Removal Foreign Object Rectum". So toward the end of the first case, as is common practice, I asked the surgeon for info on the upcoming case. And this is when it started! "It is a lime." says Dr.. Of course the shenanigans ensued.As we were getting the patient onto the stretcher to go to PACU, Dr. was standing in the open doorway and said, "I'm going for salt, and what else do we need?" Everyone in the room, in unison said, "Tequila!" And a riotous laughter commenced.Quite coincidentally, I had recently purchased a T-Shirt with a lime with an arrow over to a coconut. This was for fun for a camp shirt. This brought to mind the old song, "Put the Lime in the Coconut" by Harry Nilsson. So, you guessed it, that is what we played during the extraction of a lime from rectum case.I can remember having great fun in surgery many times in my career, but this is the latest and may I say, one of the greatest.OH MY GOD, Irreverent!

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.